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A focus on women in the health workforce on International Women’s Day

Just in time for International Women’s Day 2018 the Gender Equity Hub (coordinated by Women in Global Health and The WHO Global Health Workforce Network) held a hard-hitting webinar on Gender Transformative Approaches in the Health and Social Sectors. Drawing on expert opinion from Africa, Europe and the Caribbean the speakers described a sector in crisis, and one that needs urgent reform if we are to meet the Sustainable Development Goals and other international targets.

Kate Hawkins

08 March 2018

The health and social workforce needs gender-transformative reform

In introducing the webinar Tana Wuliji explained that the global economy is projected to create around 40 million new health and social sector jobs by 2030. However, there is a projected shortfall of 18 million health workers and the problem is particularly pronounced in low-income countries. Much of the global dialogue on women and health focuses on women’s health and does not recognise the significant contribution women make to global health. Women’s contribution to global health, where they perform about 70% of all jobs, is US$3 trillion. Half of this work is in unpaid care roles, which are finally beginning to be seen as legitimate work by international policy making bodies.

When you invest in the care economy you can boost overall employment, particularly the employment of women. With the right investments we could make a step forward on gender equity. This is the aim of the Gender Equity Hub, it is trying to accelerate this change by bringing together evidence, advocacy and a community of change-makers which can be used to accelerate gender transformative policy and practice in the health and social sector.

Women health workers face violence and sexual harassment at work

Health care is dangerous work. Shockingly, in the presentation by Sandra Massiah of Public Services International (PSI) we heard that 25% of all violence in the world of work occurs in the health sector. This occurs across all countries and occupations in the sector. Furthermore, there is a growing culture of violence and conflict in many settings and austerity measures are leading to increased inequality, which in turn leads to violent acts from third-parties.

Often there is a lack of legislation specifically on workplace violence and when it exists it is not implemented or policed (by unions and civil society). Particularly vulnerable women, for example young women and single mothers, are more frightened of reporting harassment and bullying in case they lose their employment.

She described the work of Public Services International with Lady Health Workers in Pakistan which revealed widespread sexual harassment in the field, sexual harassment by co-workers/colleagues, domestic violence, humiliation by community members, and violence from extremist groups.

Sadly, these dangers are also found in health worker education. The presentation from Varwo Sitor-Gbassie (Maternal and Child Survival Program Human Resources for Health Project) focused on Liberia. Their 2017 research aimed to increase women’s matriculation rates and reduce drop outs in pre-service health education. They found that there was very limited access to gender training in schools, there was poor access to sexual and reproductive health services, female students were not kept safe and secure, and there was sexual harassment on campus. School policies were also discriminatory. Pregnant learners were also forced to leave their studies for two years.

Fragile and conflict affected states have particular problems

Presenting on the health workforce, gender and conflict-affected and fragile states, Sally Theobald reported that there are severe challenges to recruiting health care workers (training institutions have been destroyed and staff have been killed or fled). In addition to the under-representation of women in leadership positions and the struggle to balance caring responsibilities in the home and work which are found in other settings, women in conflict settings deploy various strategies to cope. They talked of blending in so that it wasn’t so apparent that they were health care workers:

“…the rebels came, abducted the in-charge and killed a nursing aide. I managed to escape but … I ran among the community members… I would not treat my hair… they [rebels] would follow you because you look different from other people. … That is why they [rebels] did not focus on me particularly because I was exactly like the community. And I used to buy simple clothes for my baby like for the community…” (woman health care worker, Northern Uganda)

In Cambodia male health workers trained themselves to use weapons for protection, whereas female health workers found ways to escape. In Sierra Leone health workers were targeted for kidnapping to provide health services behind rebel lines; female health workers also faced the additional risk of sexual violence if kidnapped by the rebels. Despite this, women showed special resilience and courage, supported by links to families and communities.

Sandra Massiah reflected on their work in the Democratic Republic of Congo. Since 2011, nurses and other healthcare workers have faced increased violence because of the military conflict as well as suspicion and traditional views: this includes rape, molestation in addition to attacks and murder during vaccination campaigns. SOLSICO reports that between 2011 and the present, over 700 nurses were raped and 188 killed.

Promising practices

Employers have a duty of care and states must enforce this: Sandra Massiah provided valuable insights on how the trade union movement is organising to tackle both gender inequity (on pay for example), gendered violence in the health workplace, and patriarchal norms. PSI are calling for national governments and employers to support an ILO convention and recommendation on this issue. They are also assisting affiliates in linking gender-based violence and harassment to the campaign for Gender Responsive Public Services (GRPS). By promoting and encouraging the attendance and participation of members of national women’s committees in the International Labour Conference they are supporting discussion on the issues. Public services unions have a critical role to play in discussions and policy formulation on violence in society. Furthermore, Sandra argued that tax justice is a gender issue – as it contributes to the public sector and thus the achievement of the Sustainable Development Goals. Gendered reform in the sector is reliant on this source of funding.

“Collective action by organised workers has proved to be a crucial means to mount a challenge to addressing inequality in remuneration between men and women…These struggles contribute to challenging the gendered construction of the economic and social value of productive and reproductive work that these inequalities stem from.”

Gendered approaches to health systems: As Sally Theobald argued, health systems are part of, and reflect, the broader social structures they are situated within. They are shaped by gender and other relations of power. This means that we must pay attention to systems and structures that maintain inequity in our research and policy frameworks. We also need to look at norms in households and communities as these shape the way health systems operate and how unpaid care roles are distributed.

Institutional monitoring and transformation: Emma Nofal, an Athena Swan NHS Fellow from the United Kingdom presented on how inequality is being tackled in the National Health Service. The Athena Swan Programme was developed in 2005 to encourage and recognise commitment to advancing the careers of women in science, technology, engineering, maths and medicine. Emma’s team are adapting this for use in the health sector through a pilot study in Sheffield teaching hospitals. Members who sign up to the Athena Swan charter apply for an award which is dependent on a focus on promoting and supporting gender equality for women. This research has enabled them to develop a better understanding of barriers for women in progressing, accessing training, accessing maternity leave, pay banding, and how we can make the working lives of staff better.

Supporting women’s leadership: Participants suggested that we need to encourage women’s leadership in the health and social care sector and this includes men in managerial positions pushing for change, supporting training for women, and removing the barriers that they currently face. In the union sector we need to engage men to make the necessary changes in their thinking and attitudes.This may mean initiatives to educate them about what is going wrong and how they can become allies in transformative change.

Zero tolerance for sexual harassment and violence: On the webinar there was a call for a zero-tolerance approach to sexual harassment and violence, including in the health workplace. We need to centre the victims of violence and support them when they come forward (including with psycho-social interventions). Workplace policies need to be assessed and updated and workplaces need to become safe spaces for raising issues of gendered and other forms of discrimination, this may also mean tackling bullying in the workplace more generally. Leaders in global health and in politics need to openly add their voices to calls against sexual harassment and set global standards to tackle violence in the world of health work.